Ask the Doctors September 2007 Issue

Ask The Doctor: 09/07

For the past two years Iíve had intense pain in my rib cage, which has been diagnosed as costochondritis.†I stopped taking Tylenol because of the danger to my liver.†Now Iím taking Vicodin, and I still have pain. Is there something I can do for relief?

Costochondritis, an inflammation of the junctions where the upper ribs join with the cartilage that holds them to the breastbone, is a frustrating condition for both the patient and the physician. Its cause is generally unknown and its treatment often has disappointing results. Medications that have proven effective in treating costochondritis include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Aleve). Your doctor may prescribe antidepressants, specifically a category of medicines called tricyclic antidepressants, if pain is making it difficult to sleep at night, or muscle relaxants, which can also help ease pain. If these treatments fail to relieve your pain, your doctor might try a local cortisone injection into the painful area to help relieve inflammation and discomfort. A locally applied lidocaine analgesic patch (Lidoderm) has been effective for some patients. Very rarely is surgical removal of the inflamed cartilage necessary.

What can you tell me about prolotherapy?† Iím told that by injection it can cure osteoarthritis by rebuilding worn-out cartilage and that the cure is permanent.

Prolotherapy involves injecting painful ligaments and tendons with solutions (dextrose, glucose, phenol, glycerin) that are intended to stimulate production of connective tissue. Proponents believe that these treatments restore strength and stability to ligaments and joints, which may relieve pain. Prolotherapy has been used to treat a number of painful musculoskeletal conditions, such as osteoarthritis and chronic back pain. A typical course of treatment is six to 10 sessions, sometimes with multiple injections at each session. Multiple studies of prolotherapy have reported conflicting evidence regarding its effectiveness in treating chronic pain. Even the most ardent supporters of prolotherapy do not claim that it rebuilds cartilage, only that it strengthens and tightens the tissues that support the joint. As with any injection, there is a risk of infection, bleeding, or tissue damage. Currently there is insufficient evidence to recommend prolotherapy as a treatment for osteoarthritis.

Iíve been experiencing a lot of pain in my hip, but Iím 76 years old and I donít want to go through hip replacement surgery. Are there any alternatives?

Anti-inflammatory medications and physical therapy may relieve your symptoms enough to avoid surgery. Cortisone injections can provide rapid, temporary relief of joint pain caused by osteoarthritis by controlling inflammation.†Repeated cortisone injections, however, may actually speed up degenera-tion.†Viscosupplementation with sodium hyaluronate (Hyalgan) is a well-accepted therapeutic option for osteoarthritis of the knee, but limited data exist about its potential benefit for the treatment of hip osteoarthritis. In contrast to knee injections, injecting a hip joint is difficult and cannot be done reproducibly in an office setting. In order to make sure the needle consistently finds its way into the joint space of the hip, special radiology equipment is needed. Having a hip joint injection is much more uncomfortable and inconvenient for the patient than a knee injection. Also, for reasons that are not clear, hip-joint injections do not seem to work as well as knee-joint injections.